Focused SOAP Note for Anxiety, PTSD, and OCD

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name

Assignment Due Date

Introduction

Information from a patient's first appointment is used to plan each psychological intervention Refai et al (2018). Each patient's treatment starts with a full health and mental health exam that includes talking openly and honestly about mental health, drug use, and the mental health history of their family. In this case, the patient's test was written down, and the diagnostic idea was made based on what was learned from the patient during the trial. As the situation got worse, solutions were made. The patient, a 7 year old boy, was scheduled for a psychiatric exam after the pediatrician suggested he see a psychiatrist. At this time, the patient is not taking any medicine. The patient was initialy placed on DDAVP by his pediatrician which did not help.

Subjective:

CC: "My mother told me you will help me get better”

HPI: R.C. is a 7-year-old boy who was referred to a psychiatrist for a checkup after his teacher tried unsuccessfully to help him with his mood. During the interview, the mother and patient stated that a pediatrician put her son on DDAVP, which did not help him. During the chat, the patient expresses that he occasionally feels anxious. "Most of the time I feel anxious, but I don't know, just everything," the patient explained. The patient also confesses to having nightmares. "I regularly dream about getting lost, I can't find my mother or my small brother," he stated, which is terrible. It appears that a dream occurs virtually every night, although perhaps not every night.

The patient has a nightmare and cannot find his sibling or mother. When questioned if the patient is feeling disoriented. "When I'm alone," the patient says, "I worry about my mother and brother." "People at school don't like me," the patient continued. According to the patient's mother, her classmates nicknamed her nasty things because she didn't wash her hands. The patient expressed his displeasure with it. His mother never returned home. The patient claimed that his teacher was also spoiling him in class. His teacher instructed him to sit down and focus. The patient's mother was also interviewed throughout the session.

The mother voiced her concern that the patient was frightened and worried about silly things like dying, that her mother loved her brother more than him, and that she would not pick him up from school. The mother also mentioned that the patient's father had been killed in combat, but that it was too soon to tell him because he was too young. My mother feels bad about not exposing Rev.'s father and blames herself for the pastor's behavior. During the interview, Mom revealed that the patient was soaking the bed at night, that the pediatrician sent them to a Psychiatrist and prescribed DDVAP, but that the drug did not appear to help. The mother reported that the patient had trouble sleeping, reading, getting into trouble at school, flung things around the house, wanted her light on at night with the doors open, had trouble sleeping, and claimed to have a stomach ache. They are practically everyday sent home from school.

Substance Current Use: No use of any substance

Medical History:

· Current Medications: No current prescribed medication. Patient was once placed on DDAVP

· Allergies: Seasonal allergies

· Reproductive Hx: patient denies any sexual abuse

ROS:

· GENERAL: No physical pain was reported during the trial, but the person had a history of arthritis, fibromyalgia, diabetes, and diabetic neuropathy. She ended up in a clinic by herself, and there were no reports of psychomotor problems.

· HEENT: No vision problem

· SKIN: Denies any skin lesions.

· CARDIOVASCULAR: Denies any chest discomfort, pain, or chest tightness.

· RESPIRATORY: No reports of respiratory discomfort, no coughing, wheezing, and shortness of breath.

· GASTROINTESTINAL: Denies any stomach discomfort

· GENITOURINARY: Denies pain, burning, or discharge on urination and reports no flank pain.

· NEUROLOGICAL: Denies headache, dizziness, syncope, tingling, numbness, and lightheadedness

· MUSCULOSKELETAL: Denies muscle pain, muscle weakness, swelling, joint pain, and back pain.

· HEMATOLOGIC: Denies bleeding, bruising, or anemia.

· LYMPHATICS: No reports of enlarged lymph nodes and no history of splenectomy

· ENDOCRINOLOGIC: Denies cold or heat intolerance, no excessive sweating, no reports of chills, polyuria, polydipsia, and urinary frequency

Objective:

Diagnostic results:

PHQ 9 : SCORED 13

GAD 7 : SCORED 10

Assessment:

The client is awake and able to understand; he is calm, helpful, and aware. He is clean, neat, and dressed for the weather. The client's speech is clear, consistent, and loud and good in a general way. Strong language skills and a logical, goal-oriented way of thinking. He hasn't shown any signs of mental illness, like lying, deception, strange behavior, or promiscuity. Patient was cooperative, not fidgeting, makes good eye contact and able to sit still. Patient appears to be anxious and worried Affect was full range, somewhat constricted and often sad. Able to stay still. No abnormal movement noted. Gait steady and posture upright. Patient was coherent but not very logical due to worry. No acute psychosis or mood symptoms.

Differential Diagnosis:

Generalized Anxiety Disorder: Common anxiety disorder is a mental health issue that primarily affects children and teenagers Strawn et al., (2018). A young boy suffering from a common anxiety disorder feels intense worry and panic for no apparent reason. Physical appearance, previous habits, social acceptance, family troubles, failure to fulfill parental standards, personal abilities, and academic accomplishment are all frequent worries for children and adolescents suffering from common anxiety disorders. Generalized Anxiety Disorder can warn us of potential threats and assist us in planning and paying attention.

Anxiety disorders are the most common type of mental illness, affecting approximately one-third of all adults at some point in their lives. DSM-5 Diagnostic Conditions for Generalized Anxiety Disorder: Excessive anxiety and worry about the number of events or activities that occur more than six days in a row (such as work or schoolwork), a person having difficulties controlling their anxiety, and three of the six symptoms listed below are related to anxiety and anxiety: Excessive weariness, difficulty concentrating, or having your thoughts wander are all signs of restlessness. Irritability, muscle stiffness, and difficulty sleeping are all symptoms of anger.

Dysthymic Disorder: According to Strawn et al., (2018), disorders are not the result of direct physical consequences or a general health condition. Presence when suffering from two or more of the following; Overeating or hypersomnia, low energy or weariness, low self-esteem, decreased focus or difficulties making decisions, feelings of hopelessness are all symptoms of anorexia nervosa. Symptoms create severe clinical depression or incapacity in crucial professional areas. Although dysthymia was once regarded to be less severe than major depression, its consequences are now universally acknowledged to be severe, including significant functional impairment, increased morbidity, and an increased risk of suicide. The DSM-5 provides the following possibilities for diagnosing Dysthymic Disorder. A person should experience five or more symptoms within two years, at least one of which should be (1) bitterness or (2) a lack of interest or pleasure. -DSM-5 lists changes in energy levels, stress levels most of the day, practically everyday, decreased or increased appetite almost daily, self-esteem, anxiety, isolation, diet change, forgetfulness, not finishing responsibilities at work or school, guilt, and loss of energy.

Adjustment Disorder: Adjustment disorder, according to Maercker and Lorenz (2018), is a negative response to perceived stress or lifestyle changes that is characterized by a strong emphasis on stress and difficulty to adapt. And disorders are defined as the occurrence of emotional or behavioral problems as a result of stress. Correction can result from unexpected or unexpected circumstances, leading a person to feel confused, apprehensive, anxious, and disturbed, preventing the patient from returning to his normal routine. Breakups, marriage breakdowns, the end of a long-term relationship, the untimely death of a loved one, job loss, and the possibility of sexual abuse are all stressful circumstances that can lead to correction.

Reflections:

The combination of medication and therapy will help reduce the symptoms of Major Dysthymic Disorder, Generalized Anxiety Disorder, and adjustment Disorder Freire et al., (2020). It has been shown that combining psychotherapy with medication is a good way to treat anxiety and depression, especially if the symptoms are not caused by the medication or by other health problems. This client is encouraged to keep going to his or her regular therapy sessions because it will help him or her build on or come up with ways to deal with pressures now and in the future. When combined with psychopharmacology, mental-behavioral therapy is the best way to treat a lot of mental health problems. The client was told to follow his primary care doctor's orders to do all of the necessary physical exercises, such as getting lab and imaging tests when needed.

One thing I could have done differently as a PMHNP is to meet the patient first to develop a therapeutic relationship, then address questions unrelated to scheduled sessions to assist build acceptance. the environment Without looking biased, ask open-ended inquiries about the patient's personality, disease, or personality. Inquire about the patient's sexual orientation and preferred mode of communication. Trust, respect for diversity, respect for religion, equality, fairness, and social justice are all characteristics of cultural suitability that should be considered during any interview or encounter between a health practitioner and a patient. When I talk to a patient about their symptoms of mental illness, I look at the way they look, talk, and act to see if there are any clues that can explain their symptoms.

Case Formulation and Treatment Plan:

Medication and speech therapy were used to treat the patient. Psychotherapy will assist the client in changing their feelings and behaviors. The patient's mother will be given an instruction booklet, as well as tasks and follow-up consultations on topics related to healing and coping. Bed-wetting can be avoided by reducing the quantity of alcohol a child drinks in the evening, avoiding caffeinated meals and beverages, and encouraging regular bathroom usage during the day, according to Gronemann et al., (2021). The mother was instructed to wake the patient up at night to urinate and to change the patient's clothes before going to school in the morning. The patient should be given personal hygiene treatment. In the event of an emergency, the provider gave the patient two phone numbers to call: 911 emergency and the Customer Problem Line. Doctors' and clinicians' reports were evaluated for comprehension, cooperation, and continuity of care. If the patient's mother had any questions or worries regarding the development of any unpleasant or unexpected side effects, she was instructed and urged to contact their primary care physician or the nearest emergency facility.

Conclusion

During the interview, the PMHNP student should try to give the patient his or her own facts or information so that he or she can give the right personal or personal care, even though the supervisor has already given the student information about the patient. PMHNP should avoid Avoid discrimination based on the patient's personality, health, or what the doctor says about the patient. Also, ask the patient if they'd like to talk privately if they have something they'd like to share with you in private. Then, find out about the patient's stress, depression, identity, and sexual orientation. It is also important to know what makes one mental state different from another.

References

Freire, R. C., Cabrera-Abreu, C., & Milev, R. (2020). Neurostimulation in anxiety disorders, post-traumatic stress disorder, and obsessive-compulsive disorder. Anxiety Disorders, 331-346.

Gronemann, F. H., Petersen, J., Alulis, S., Jensen, K. J., Riise, J., Ankarfeldt, M. Z., ... & Osler, M. (2021). Treatment patterns in patients with treatment-resistant depression in Danish patients with major depressive disorder. Journal of Affective Disorders, 287, 204-213.

Maercker, A., & Lorenz, L. (2018). Adjustment disorder diagnosis: Improving clinical utility. The World Journal of Biological Psychiatry, 19(sup1), S3-S13.

Refai, M., Andolfi, M., Gentili, P., Pelusi, G., Manzotti, F., & Sabbatini, A. (2018). Enhanced recovery after thoracic surgery: patient information and care-plans. Journal of thoracic disease, 10(Suppl 4), S512.

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070.